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Mahajan M Transposition of bilateral maxillary canine and 1st premolar

Case Report
Orthodontic treatment of transposition of bilateral maxillary canine and
1st premolar by maintaining the transposed position: A case report
Monika Mahajan

From, Assistant Professor, Department of Orthodontics & Dentofacial Orthopedics, Himachal Pradesh Government Dental
College and Hospital, Shimla, H.P. India.

Correspondence to: Dr. Monika Mahajan, Department of Orthodontics and Dentofacial Orthopedics, Himachal Pradesh
Government Dental College and Hospital, Shimla, H.P. India. Email: monika.hemender@gmail.com

Received - 15 February 2019 Initial Review – 5 March 2019 Accepted – 20 March 2019

ABSTRACT

Bilateral tooth transposition between maxillary canine and 1 st premolar is a rare finding and poses a challenge to any
orthodontist to treat. In definitive treatment plan, one of the treatment alternatives can be finishing the case with alignment of
involved teeth in their transposed position whereas the other option is to correct the transposition orthodontically and
establishing the natural tooth order. Here a case is presented where transposed positions were maintained with the philosophy
to treat by minimizing the negative factors.

Keywords:- bilateral transposition , orthodontic treatment

T
ooth transposition is a developmental alteration predilection and is generally associated with other
resulting in a deviation in tooth position, clinically anomalies such as agenesis (40%), deciduous canine
identified as the interchange of two adjacent teeth, retention (50%) and peg shaped maxillary lateral incisor
that alters the natural order of the dental arch [1-3]. Tooth (25%) [1,6,8]. Unilateral canine transposition happens
transposition can be complete, when both the tooth crown more frequently (79%) and the left side is more frequently
and the root are transposed, or incomplete when only the affected (69%) [1,9]. Bilateral transposition has been
clinical crown is transposed but the root apex remains in reported in 5% of cases [2]. Transposition between canine
relatively normal position [4]. The 5 types of tooth and maxillary 1st premolar occurs in 0.135% to 0.510% of
transpositions observed in upper jaw are classified by Peck the population [4,10]. In Japan, the incidence ranges from
and Peck according to the teeth involved as: (1) Canine to 0.065% in general population to 0.660% in orthodontic
1st premolar; (2) Canine to Lateral Incisor; (3) Canine to 1st patients [10,11]. Elsewhere occurrence ranges from
Molar position; (4) Lateral Incisor to Central Incisor; (5) 0.380% in a Turkish population to 0.510% in Africa
Canine to Central Incisor position [2]. Transpositions [10,12].
mostly involve the upper arch and unilateral transposition
is more common than bilateral transpositions with the left Tooth transposition can hinder esthetic and functional
side being more often involved [3-5]. aspects of dentition. Postulated causes of tooth
transposition include inversion of the tooth buds during
The canine is one of the most commonly involved teeth development, alteration of the tooth eruption pattern, the
in the transposition phenomenon, changing its eruptive presence of deciduous teeth beyond the maximum time
place with the lateral incisor or the 1st premolar in most limit for the development of the permanent teeth and any
cases [5-7]. Canine transposition has a maxillary dental trauma during childhood. A genetic origin also has

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Mahajan M Transposition of bilateral maxillary canine and 1st premolar

been reported as the main etiologic factor thus supporting a including the 3rd molars were present with complete
theory of multifactorial heredity in transposition of teeth. bilateral transposition of maxillary canines and 1st
Maxillary canine and 1st premolar transposition is premolars (Fig 3).
currently considered a tooth position anomaly caused by
genetic factors along with a multifactorial inheritance
pattern. According to Peck and Peck various observations
corroborate the polygenic inheritance theory such as the
high prevalence of dental anomalies related to maxillary
canine -1st premolar transposition, its bilateral occurrence,
familial occurrence with significant differences in
prevalence among males and females [3-5,13-18]. We
hereby present a case to demonstrate complete bilateral
transposition of maxillary canine to 1st premolar along
with the treatment option selected.

CASE REPORT
Figure 2: Pre-treatment intra-oral photographs
The patient, a girl aged 13 years, reported to the
Department of Orthodontics, with the chief complaint of
mild crowding along with tooth malposition in upper arch.
An extraoral examination showed a pleasing face with
facial symmetry and a straight profile (Fig 1). An intraoral
examination revealed that she had all her permanent teeth
erupted except maxillary left canine which had not
erupted. There were bilateral retained deciduous maxillary
canines present.

Figure 3: OPG showing complete bilateral maxillary

transposition between canine & 1st premolar

Treatment objectives were based on multidisciplinary

approach to improve esthetics, establish oral health and
function as well as to attain stability forms. The patient
was referred for the required orthodontic treatment with
the aim of achieving treatment objectives mentioned
below:
a) To relieve the crowding of upper and lower anterior
Figure 1: Pre-treatment extra-oral photographs
teeth.
b) To establish a functional class I molar and canine
The clinical examination revealed Angle’s molar
relationship.
relationship as class I on the left side and end on the right
c) To correct the transposition and establishing the natural
side. There was a complete transposition of maxillary
tooth order if possible.
canine and 1st premolar on the right side clinically. The
maxillary right 1st premolar was rotated mesiopalatally and
Orthodontic treatment was initiated by bonding upper
maxillary canine was placed buccally distal to 1st
lower arches with pre torqued and pre angulated brackets
premolar. The left maxillary canine was unerupted (Fig 2).
with a 0.022 inch slot of MBT prescription. Tooth
The panoramic radiograph showed that all permanent teeth

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Mahajan M Transposition of bilateral maxillary canine and 1st premolar

movement was started with light forces. Both retained post treatment lateral cephalogram shows maintenance of
deciduous canines were extracted. The 1st premolars were skeletal class I bases (Fig 6). The panoramic radiographic
moved mesially and the canines were moved distally to 1st view demonstrated normal alveolar contours and no sign
of root resorption or any other damage to canine or
premolar position bilaterally. Fixed appliances were
premolar was seen (Fig 7).
removed after 28 months of orthodontic treatment and
removable Hawleys retainers were placed in both mandible
and maxilla to maintain orthodontic correction. The patient
was suggested to get bilateral odontoplasty of the tip of the
cusp of canines to mimic the anatomy of premolar but she
did not feel the need and hence declined but was advised to
undergo it in near future.

The post-treatment results showed the patient with a

very pleasant face and smile (Fig 4). Intraorally the patient
attained correction of crowding of teeth with maintaining
Angles class I molar relationship with an ideal overjet and
overbite (Fig 5). Figure 6: Post-treatment lateral cepalogram showing class
I skeletal bases

Figure 4: Post-treatment extra-oral photographs Figure 7: Post-treatment OPG shows finishing in

transposed position

DISCUSSION

The maxillary canine to 1st premolar transposition is

clearly the most frequently reported maxillary
transposition type [5,7]. The treatment of transposition can
be classified as interceptive or definitive depending on
when the transposition is diagnosed. Interceptive treatment
is performed on patients at the age of 6 and 8 years after
OPG and intra oral examination reveals presence of tooth
transposition at the initial stage. Interceptive treatment can
be adapted before transposition is complete, which
normally occurs around 10 years of age. Hence thereafter a
Figure 5: Post-treatment intraoral photographs
definitive treatment approach should be adapted [3,19]. In
definitive treatment, one of the treatment alternatives can
The challenge of correcting a transposition is to be finishing the case, with alignment of involved teeth in
accomplish it while maintaining periodontal health. The their transposed position. The other option is to correct the

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Mahajan M Transposition of bilateral maxillary canine and 1st premolar

transposition orthodontically and establishing the natural REFERENCES

tooth order. Extraction approach is preferred when a severe
1. Chatopadhyay A. Transposition of teeth and genetic
arch deficiency persists. It is not advised to correct
etiology. Angle Orthod. 1998;66:147-152.
transposed teeth in permanent dentition because of
2. Peck S, Peck L. Classification of maxillary
potential risk of damaging the teeth or supporting
transpositions. Am J Orthod Dentofacial Orthop.
structures. Therefore alignment of the involved teeth in
1995;107:505-507.
their transposed position seems to be the best alternative 3. Peck S, Peck L, Kataja M. Mandibular lateral incisor-
with the positioning of teeth in the new sequence [6,15]. canine transposition, concomitant dental anomalies, and
genetic control. Angle Orthod.1997;68:455-466.
In our case, a non-extraction approach was considered. 4. Shapira Y, Kuftinec MM. Maxillary tooth transpositions:
Thereafter keeping the transposed order of the teeth or Characteristic features and accompanying dental
recreating the natural tooth order was presented as two anomalies. Am J Orthod Dentofacial
treatment alternatives to the patient. If it is opted to keep Orthop.2001;119:127-134.
the natural tooth order, treatment becomes longer and more 5. Joshi MR, Bhatt NA. Canine transposition. Oral Surg
difficult. However, if it is opted to keep the transposed Oral Med Oral Pathol. 1971;31:49-54.
tooth order, different variables such as different root 6. Shapira Y, Kuftinec MM. Tooth transpositions- a review
prominence, different height of gingival scallops as well as of the literature and treatment considerations. Angle
the shape and size of the transposed premolar has to be Orthod. 1989;59:271-276.
considered [20]. Esthetic and occlusal considerations 7. Joshi MR, Gaitonde SS. Canine transposition of
suggest that aligning the transposed teeth while keeping extensive degree: a case report. Br Dent J.1966;121:221-
their transposed positions would be unacceptable but, as a 222.
general rule it is not advisable to correct a transposed tooth 8. Newman GV. Transposition: orthodontic treatment. J
order due to insufficient buccopalatal width of bone Am Dent Assoc.1977:94:554-557.
9. Shapira Y, Kuftinec MM. Maxillary canine – lateral
support for the movement of two adjacent teeth in different
transposition-orthodontic management. Am J Orthod
directions, especially after eruption [17]. Many reports
Dentofacial Orthop.1989;95:439-444.
showed recession at the gingival margins of the
10. Tseng YC, Chang HP, Chou TM. Canine Transposition.
repositioned canines because of long journey of canines
Kaohsiung J Med Sci.2005;21:441-7
through the dense buccal compact bone [17,20]. 11. Sato K, Yokozeki M, Takagi T, Moriyama K. An
orthodontic case of transposition of the upper right
We treated this case with the philosophy to minimize canine and first premolar. Angle Orthod.2002;72:275-8.
the negative factors. The key to success is to diagnose the 12. Burnett SE. Prevalence of maxillary canine- first
case early and begin the treatment, thereby minimizing the premolar transposition in a composite African sample.
possibilities of injuring the surrounding tissues [2,9,13]. Angle Orthod.1999;69:187-9.
One must take into consideration the esthetic factors, 13. Parker WS. Transposed premolars, canines, and lateral
occlusion, canine root apex position, periodontal support, incisors. Am J Orthod Dentofacial Orthop. 1990;97:431-
patients age along with treatment duration, patient 48.
cooperation when correcting the transposed teeth. 14. Gholston LR, Williams PR. Bilateral transposition of
maxillary canines and lateral incisors: a rare condition .J
CONCLUSION Dent Child.1984;51:58-63.
15. Laptook T, Silling G. Canine transposition- approaches
Transposition is an anomaly of tooth position which is a to treatment. J Am Dent Assoc.1983;107:746-748.
challenge for an orthodontist. When correcting it different 16. Dayal PK, Shodhan KH, Dave CJ. Transposition of
factors should be taken into consideration such as age of canine with traumatic etiology. J Indian Dent
patient, esthetics, occlusion, treatment time, patient Assoc.1983;55:283-5.
comfort and periodontal support. The treatment allowed us 17. Peck L, Peck S, Attia Y. Maxillary canine- first premolar
to place the teeth in their transposed order. Our patient was
transposition, associated dental anomalies and genetic
satisfied with the esthetic results obtained and has good
basis. Angle Orthod.1993;63:99-109.
oral health.

Vol 8| Issue 1| Jan– Mar 2019 J Orofac Res 11

Mahajan M Transposition of bilateral maxillary canine and 1st premolar

18. Lai HH, Chang HF. Analysis of tooth transposition. J

Taiwan Assoc Orthod.2004;16:38-43. How to cite this article: Mahajan M. Orthodontic
19. Plunkett DJ, Dysart PS, Kardos TB, Herbison GP. A treatment of transposition of bilateral maxillary canine
study of transposed canines in a sample of orthodontic and 1st premolar by maintaining the transposed position:
patients. Br J Orthod.1998;25:203-8. A case report. J Orofac Res. 2019;8(1):8-12.
20. Kuroda S, Kuroda Y. Non extraction treatment of upper
canine –premolar transposition in an adult patient. Angle Funding: None; Conflict of Interest: None Stated.
Orthod. 2005;75:472-477.

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